Chapter XVI: Front Matter (16)

Large subserous, fibrous, or fibro-cystic tumors are almost always covered with a network of great vessels, generally furnished by adhesions to the omentum. These vessels should be ligated in bundles by two ligatures around each bundle at least two inches distant from the uterus. If the two ligatures are not thus widely separated from each other, when the division between them is made the collapse and retraction of the vessels will be so great that they will not hold. If in detaching adhesions a bleeding surface is left on the tumor or abdominal wall, the bleeding should be arrested by ligatures applied before the tumor is lifted from its bed. When it is necessary to remove the uterus, a double ligature around its substance should be applied; also, when practicable, before the tumor is lifted out. In this method of securing the vessels we will avoid the terrible hemorrhage that would otherwise follow the removal of the tumor. The pedicle should then be brought out and secured by pins in the wound. The cleansing of the peritoneal cavity and closure of the wound should be done as in ovariotomy. The after-treatment is also the same as in bad cases of ovariotomy.

I have not thus far mentioned the treatment of fibrous tumors by electrolysis; and as the profession has not generally consented to the adoption of this measure as safe and efficacious, I will refer the reader to an account given of that process and its results in my work and other standard works on gynecology.

{271}

SARCOMA OF THE UTERUS.

BY W. H. BYFORD, M.D.

This disease is as much entitled to the clinical definition given to cancer as any of the varieties of that malignant affection. Miller, as quoted by West, says: "Those growths may be termed cancerous which destroy the natural structure of all the tissues; which are constitutional from their very commencement or become so in the natural process of their development; and which, when once they have infected the constitution, if extirpated, invariably return and conduct the person who is affected by them to inevitable destruction." If we substitute the word malignant for cancerous in the above quotation, the definition would include sarcoma as well as carcinoma. It will be found upon comparing sarcoma with fibrous and cancerous tumors that it possesses clinical and histological features common to both. If it is not indeed the result of a transition of fibrous tumors into a malignant form of disease, it is a connecting link between fibromatous and carcinomatous affections, and illustrates in a remarkable manner a relationship of these two forms of growths--viz. the morbid proliferation of the tissue resembling those of the structure in which they originate. Sarcoma has its origin in the fibrous portion of the connective tissue, as do many of the fibrous tumors. It consists of a redundant proliferation of the cells of that tissue, while the fibrous tumor is constituted of a morbid proliferation of the fibrous element of the connective and muscular tissues. Cancer now is admitted to be an excessive production of the cells of the epithelium; this excessive growth of the cells inhabiting these structures, sarcomatous and epithelial, seems to give to them respectively the feature of malignancy. The fibrous tumor is contained in a capsule; both forms of these malignant growths invade the tissues without any such limitation. In this respect the two latter resemble each other and differ from the former. In sarcoma the cells are mingled intimately with the fibres, and are not generally contained in alveoli, or nests, as they are sometimes called. Cancerous cells are always surrounded by alveoli. Sarcoma in many instances resembles very closely the fibrous tumor. In malignancy it is very much like the cancerous tumor.

CLINICAL HISTORY.--The early symptoms of sarcoma are leucorrhoea, hemorrhage, and tumefaction. The discharge from the genital organs resembles that of fibrous tumors. This does not generally possess an offensive odor, but as the disease advances necrosis of the tumor occurs to a greater or less extent, and then the smell of the discharge comes to {272} resemble that of cancer. The necrosis does not take place at the expense of the uterine tissues, but is a process of disintegration going on in the growth. The ulcer resulting does not corrode the uterus, but it eats away the tumor. It in this respect resembles epithelial fungus. The tumor formed by the sarcomatous deposit is sometimes polypoid, and presents the appearance of the fibrous polypus. In other instances it resembles to the touch a submucous fibrous tumor, and again in others it is diffusely disseminated into the whole structure of the uterus. When thus diffused, like cancer it invades the neighboring organs. When the tumor projects from the inner surface of the womb, and has attained a considerable growth, limited necrosis occurs, and sloughs of varying size take place, and offensive sanious discharges occur very similar to the flow observed in cancer.

The general symptoms at first are slight, consisting of obscure pelvic pains and pressure and increased discharge. Gradually septicæmia is developed, and this is the condition in which the patient usually dies.

DIAGNOSIS.--There is nothing in the symptoms by which we can arrive at a correct diagnosis, as in the early periods they resemble those of fibrous tumors so closely as to be undistinguishable from them, and in the latter cancer neither manual nor ocular examination will give us any more definite information. Their qualities in this respect also are in the early stages of development those of fibrous tumors, and in the latter of some forms of cancer. We are therefore reduced to the evidence afforded by microscopical examination.

When the tumor is in such a position and of such a consistence that we can remove a fragment from it, we can study its histology. There are two varieties, as distinguished by the shape and size of the cells. One variety is called the small-celled sarcoma, from the size of the cells; they are round, or nearly so, in shape. The other is called the spindle-celled sarcoma. In some specimens of this variety the cells are much larger than others; and hence there is the large and small spindle-celled sarcoma. The cells are different among the fibres of the tissues affected, and in rare instances some of the cells are contained in imperfectly-formed alveoli, in this respect showing a further analogy to the growth in cancer.

PROGNOSIS.--The malignancy of sarcoma is now universally recognized in the known facts of its persistency in returning when removed, and its simultaneous existence in many organs of the body. This acquired or innate constitutional dissemination is not constant--no more than in cancer, perhaps less so. Hence when the size of the tumor is small and apparently isolated there is some encouragement to attempt a cure.

The comparative prognosis is also probably better than cancer, as it pursues a less rapid course of development, and hence the patient may survive for a longer time.

The local dissemination of the cells cannot always be measured, and that their dissemination into the surrounding tissues may reach much beyond the boundaries of the apparent tumor must be regarded as an important element in considering the subject of prognosis in connection with treatment by ablation or cauterization. The widespread local dissemination of the cells of this growth is doubtless an explanation of the term at first applied to it--viz. recurrent fibroid.

{273} TREATMENT.--It will not be necessary to consume the time of the reader by giving the treatment of sarcoma in detail, as most of it is identical with that of Cancer, and may be found under that head. I will only call attention to the excellent palliative effects of ergot: this drug will often arrest, and generally modify, the hemorrhage so often one of the most annoying symptoms. When the tumor is in a state of progressive necrosis, protrudes like a submucous fibrous tumor, or is pendulous, resembling the fibrous polypus, it may, by inducing contraction of the uterus, be expelled, partially if not completely, and thus for the time being do away with the source of sepsis. I have in several instances been highly gratified with its effects in this way. In one case, when the patient was so overwhelmed with symptoms of septic fever as to cause apprehension of immediate dissolution, the administration of ergot expelled large masses of sloughing tissue, and so cleansed the uterus that the symptoms subsided, the patient rallied, and lived several months in comfort. Not less than four times this process of expulsion was successful in relieving the same patient for long intervals: each time the medicine was administered relief was so marked that both she and her friends anticipated recovery.

{274}

CARCINOMA OR CANCER OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.

While it is possible that in very rare instances the scirrhous or colloid form of cancer may attack the uterus, the practitioner will seldom meet with either. I will therefore describe but two varieties--the soft or medullary, and the epithelial. Although there is much difference histologically and microscopically, they are so nearly allied in their clinical history that I feel justified in placing them together. In the clinical description of carcinoma I shall be governed more by what I have seen at the bedside than by the observation of others.

Medullary or Soft Cancer.

I use this term in a comparative sense. By it I mean a tumor caused by a carcinomatous deposit that infiltrates, enlarges, and renders more fragile than natural the parts attacked, which after a greater or less time undergo necrotic ulceration, death, or solution of the morbid growth, giving rise to extensive ulceration. I have never seen this variety convert the uterus into a tumor of encephaloid consistence. The deposit usually begins in the extremity of the cervix and extends up to the body, and without reference to the boundaries of different tissues attacks and involves the fibrous, mucous, and serous tissues, extending to any organ or substance that may be contiguous, thus infiltrating the bladder, rectum, connective tissues in the broad ligaments, and ovaries. The necrotic ulcerations of the part where the disease began, and the extension of the deposit in the more distant parts, progress simultaneously, the one diminishing while the other is increasing the bulk of the parts involved. This kind of progressive local dissemination and necrosis of cancerous matter often results in the more or less complete destruction of the uterus, bladder, and rectum.

Accompanying these morbid processes in the pelvis, cancerous cells migrate to other and distant portions of the body, creating new centres of carcinomatous disease. These multiple centres of disease are probably in all instances caused by the errant products of the pelvic disease. This view of the subject makes the general carcinomatous disease a constitutional infection, the same as the wandering cells of the chancre give rise to constitutional syphilis.

ETIOLOGY.--No one circumstance seems so intimately connected with {275} the origin of cancer of the uterus as age, more than half the cases occurring between the fortieth and fiftieth years, 33 per cent. between the thirtieth and fortieth; this leaves only 20 per cent. for all other ages. It very seldom attacks the young under twenty-five years or the old over fifty. So far as I have been able to examine statistics, I am not sure that cancer occurs any more frequently among multipara than nullipara. The fact that the number of childbearing women far exceeds those who are not married nor fruitful is likely to mislead us in this respect. Race does not seem to afford even comparative exception. The negro and North American Indians seem to be subjects of cancer as frequently as the European races.

If there is anything in the idea of heredity as a causative influence, it must be rather through physiological similitude of children to parents than the transference of taint from the former to the latter. If cancer is a degeneration of tissues, as the effect of a law that organs in certain individuals undergo dissolution at a particular age, we can understand that the child may inherit such physiological effect from the mother. The cell-formation of the organs of the child will be capable of reaching the same period at which the disease was developed in the mother, when the normal histological changes will be interrupted and dissolution begins. In this view of the subject the child would by virtue of its organization inherit the mode of dying evinced in the mother.

Old writers, assuming that cancer was the result of a peculiar dyscrasia, described the state of general health as a causing condition. It does not seem, however, that the majority of people in whom cancer is developed exhibit any signs of ill-health until the local disease has made sufficient advance to account for their symptoms. Indeed, many present the appearance of a faultless condition of general health until the disease is discovered to have made hopeless progress. The same may be said of the local condition. It so often happens that we are assured by a patient that she had been congratulated by her friends as one especially favored by exemption from female weaknesses. I have yet to witness any evidence that chronic inflammation, congestion, or laceration of the uterus predisposes to malignant disease of any kind.

I do not mean by this to say that patients having chronic uterine ailments may not become the subjects of cancer of the uterus. There is nothing in the gross anatomy or the histological construction of cancer to indicate an analogy to inflammation. The allegation that the long-continued irritation of laceration invites a malignant deposit in the tissues involved is mere assumption, and should rank as an unproved hypothesis.

The location of the primary lesions is usually in the cervix, but occasionally it attacks other parts of the uterus, the body next in frequency to the cervix, and less commonly the fundus.

CLINICAL HISTORY.--The early stage of cancerous development is not marked by obvious symptoms. Judging from my own observation, a bloody discharge more frequently attracts the attention of the patient than any other symptom, and this does not appear until the deposit is somewhat extensive, and it indicates necrosis. The loss of blood is sometimes copious, but generally moderate in quantity. It may be intermittent or continuous. Not infrequently in menstruating women {276} it assumes the form of menorrhagia. The next symptom generally is a discharge of ichor, usually colored, sometimes entirely clear. With the appearance of the serous discharge the cancerous odor becomes apparent and continues. These two exhausting and disgusting symptoms continue alternating with each other with the persistence of fate.

Another symptom of cancer of the uterus is pain. It is not, however, generally an early symptom. Often it is entirely absent until the disease has made great progress. When noticed early, the pain is sharp and lancinating, consisting of recurring twinges rather than of continuous pain. When it does not occur until later in the progress of the case, it is such as arises from the accompanying congestions and inflammations.

GENERAL SYMPTOMS.--No general symptoms are manifest until the disease has made considerable advance, and often not until there begin to be degenerations in the tumor. It would seem, indeed, that the growth of cancer was not a morbifacient process, and that constitutional disturbance results from the septic influence exerted by the necrosis of the tumor.

The absorption and circulation of the products of decomposition at the extremities of the tumor through the nervous centres and secreting organs soon induce nervous ailments and derange the functions of all the important vital organs. A continuance of the derangement thus inaugurated, and kept up, eventuates in fully-developed septic fever, by which the energies of the patient are exhausted. The uniformity with which septicæmia terminates the existence of these unfortunate patients renders the exceptions to the above description very rare indeed. While patients think they are being eaten up by cancer of the womb, they are really dying from slow poison caused by absorption of dead tissues.

DIAGNOSIS.--In the great majority of cases the diagnosis of cancer is easily arrived at. For reasons already stated the disease is not suspected until the deposit is extensive and obvious changes in the shape and consistence of the cervix occur. It is enlarged, very hard, and generally irregular in shape. In most instances it is very much enlarged, measuring from one to ten times its natural diameter; the tissues are devoid of elasticity; and nodosities, projections, and sulci deform the cervix in a manner and to a degree that change the shape of the organ as nothing else does. Add to this the stinking sero-sauguinolent discharge, and the diagnosis is complete. By the time these physical changes become diagnostic features of the case the uterus becomes fixed, the immobility being obviously dependent upon the extension of the deposit to the vagina, bladder, and contents of the broad ligament. The invaded tissues become as hard and unimpressible as the uterus. We could hardly mistake cancer in this stage of development for any other disease, and as the general practitioner will seldom see it before the most of these changes have occurred, the diagnosis will generally be easy. When the tissues break down to a considerable extent the ulcers, if they can be so called, are very irregular in shape, greatly excavated, have a hard, rough, granular bottom, and are not tender to the touch. Generally they bleed upon being handled. The hardness, enlargement, irregularity of shape, and fixedness are as conspicuous features during the process of destruction as they are in the stage of deposit.

{277} The demonstrative portion of the diagnosis, however, is derived from the histology of the deposit. "Histological examination of the changed uterine tissues shows, as in every carcinoma, a stroma of small alveoli filled with polymorphous cells, generally arranged without order; sometimes those of the periphery are implanted regularly on the wall of the alveolus. The stroma composed of connective tissues frequently contain also smooth, muscular fibres."[1]

[Footnote 1: Cornil and Ranvier, translated by Shakespeare and Simes, p. 696.]

PROGNOSIS.--This form of carcinoma uteri will bear no other than a desperate prognosis. I doubt whether it is ever discovered until the deposit has reached an extent locally that renders complete ablation impracticable. In addition to this consideration the malignant cells are disseminated, if not degenerated, in distant parts.

Nature in an infinitesimal number of cases institutes curative processes. These processes consist of extensive sloughing and a species of atrophy in the morbid growth. The growth ceases to enlarge, becomes smaller, and finally disappears. Very few men are lucky enough to witness the fortunate results of these processes. Art is powerless to cure, but may do much to palliate the suffering connected with the fatal march of carcinoma.

The duration of uterine cancer is greater in the old than in the young. In the former it may last several years; in the latter it often terminates fatally in a few months.

TREATMENT.--Taking the above history of the disease as true, it will not be necessary to say much about curative treatment. If we should find a case of cancer in which the cervix is not enlarged as high up as the junction of the cervix and vagina, I would advise amputation of the cervix and excavation of the uterine tissues as extensively as possible. The amputation and excavation may be performed by means of hooks and scissors, as in epithelioma. Taking the statistics of Freund's operation, as practised and modified by himself and others, as my guide, I am not disposed to sanction or advise the complete extirpation of the uterus for this form of cancer.

The subject of palliative treatment of cancer for the relief of local symptoms, and the amelioration of the general suffering caused by the septic fever, with which the patient usually dies, is more hopeful. The local symptoms requiring palliation are the sometimes disastrous hemorrhages, fetor, acridity of the sanious discharges, and pain.

The tampon made of cotton saturated with the solution of the subsulphate of iron is generally a very effectual means of treating the hemorrhages, while it also temporarily removes the fetor and acridity of the discharges. The tampon saturated with a strong solution of alum is also very effective. Frequent injections and ablutions with a weak solution of carbolic acid or permanganate of potassium will also be very useful in keeping the discharges free from odor. Much comfort may also be derived from small pellets of absorbent cotton introduced just within the vulva to absorb the discharge. Their frequent removal will of course be necessary, but they will be found to protect the external parts from excoriations that would otherwise occur. Applications of tincture of the chloride of iron or solution of hydrate of chloral carefully made to the raw surface upon the cervix very materially correct the foulness {278} of the discharges and lessen the process of necrosis which is continually taking place.

The local and general use of anodynes is about our only means of relieving pain. They may be used locally in suppositories introduced into the rectum or vagina, or hypodermically or by the stomach in such quantities as may be required. Further detail is unnecessary in reference to the use of anodynes, as the quantity, quality, and mode of administering them will depend so much upon the urgency of the pain and the character of accompanying symptoms.

The treatment of the septicæmia is both general and local.

The general treatment consists of such measures as will sustain the vital powers. Tonics of quinine and iron are the remedies that will be of most service, and judiciously used will greatly ameliorate the symptoms of exhaustion. A very important item in the treatment of these prolonged cases of septic fever is a well-selected diet--the more nutritious and easy of digestion the better. It should consist largely of fresh mutton, beef, poultry, game, milk, and butter. The bowels will be generally troublesome in the early part of the time by constipation, and in the later by diarrhoea. For the former a diet containing fruit and coarse flour bread will often enable us to dispense with cathartics, which are generally both exhausting and annoying. For the diarrhoea opiates can be used freely, as also bismuth, pulverized charcoal, etc. etc.

But the most important as well as the most effective measure with which to combat this destructive fever is to keep the raw surface of the tumor as free as possible of necrosed material. This is done most effectively by the sharp curette or Simon's spoon. The whole of the ulcerated surface should be thoroughly scraped off with one of these instruments. The parts completely exposed by Simon's retractors should be scraped energetically until the solid tissue is reached. It should be remembered that the tissues exposed are not sound, but are cancerous deposit. The sacrifice of it, therefore, is not a matter of importance, so that the excavation if not fearlessly should be thoroughly done. An operation of this kind is attended with two dangers. One is the removing so much substance as to open the peritoneal cavity, bladder, or rectum; and the other is hemorrhage. Care will enable us to avoid the former; and, when formidable, the latter may be staunched by the astringent tampon already mentioned.

This operation is only intended as a palliative measure, and it sometimes proves remarkably beneficial. After it the patient will occasionally rally so much and become so comfortable as to indulge in the belief that she is on the road to recovery. The amelioration lasts sometimes months. It will often be profitable to repeat the scraping several times, especially if the case is advancing slowly. It will usually not only make the patient more comfortable, but greatly protract her existence.

Epithelioma of the Uterus.

This malignant disease differs in several respects from the cancer already described. The morbid cell-growth in that form of cancer takes place in the lymph-spaces of the connective tissues of the cervix {279} and uterine body. The lymph-spaces are converted into alveoli or nests in which the cells are developed until they become greatly distended and changed in shape. The lymph-spaces thus occupied freely communicate with each other, and of course with the lymphatic vessels. Hence, the rapid dissemination of the cells locally and the ease with which they find their way to distant parts of the system.

The cells in epithelioma are developed on the free surface of the mucous membrane. From this surface the cells seldom travel to any great distance, and consequently the disease often does not become general. Epithelioma is cancer of the mucous membrane of the uterus, while the other form is interstitial cancer of the uterus. The dense mucous membrane serves as a barrier to the passage of the cells into the surrounding tissues. After the disease has existed for a long time, the surface of the mucous membrane is impaired, and it does not resist the dissemination of the cells. Then the process of cell-dissemination is a result of partial destruction of the membrane. In cancer of the uterus they are disseminated early, and possibly from the beginning, because they are generated within the lymph-spaces, with which the lymphatic vessels are continuous.

Epithelioma of the uterus very rarely assumes the form of an ulcer; generally it is a deposit upon, or growth from, the surface of the mucous membrane. The growth assumes shapes that vary with the different localities. If the extremity or external surface of the cervix is the seat of the disease, it usually projects into the vagina as a fungus which may grow large enough to fill up that cavity. Much more frequently the cervix is enlarged and is covered with a stratum of epithelial deposit very frail in texture that bleeds freely when rudely touched. This fungous growth or deposit does not affect the mobility of the uterus, even when the cervix is considerably enlarged. When the morbid deposit takes place in the cavity of the uterus, it often does not project from the os uteri to any extent, but is confined to the cavity. When the cavity is filled up by an epitheliomatous growth emanating from the entire surface of its lining membrane, we seldom see anything more than an ashy-looking substance filling up the external os uteri. Sometimes the growth covers the whole of the mucous membrane of the body and neck, including the external covering of the latter part.

CLINICAL HISTORY.--The clinical history of epithelioma is essentially the same as that of the other form of cancer, and consequently need not be given in detail. The main symptom is hemorrhage, with an abundant and stinking sanious discharge.

DIAGNOSIS.--In examining with the finger and with both hands it will be found that the uterus is movable and not much, if any, enlarged. If the case is of the ulcerated variety, the finger may not detect the lesion; if, on the contrary, there is a fungus, it will at once detect it. Should the deposit not project from the os externum, the finger may not recognize its presence. Upon exposing the cervix to view in the ulcerative variety an ulcer of a light ash-color will be seen, presenting an irregular outline slightly excavated, and if the probe is applied to it the bottom and sides of the ulcer will be found of the same firmness and consistence as the uterine tissues. It is not indurated. If a fungus exists, it can be seen and examined. When not bleeding it is also ash-colored. The {280} consistency of the projecting mass is sometimes tolerably firm, but more frequently it is quite frail and gives way under moderate pressure. Should the deposit be inside of the uterus, the os will be slightly dilated and filled with a gray substance.

The probe will readily pass through this frail material and enter the uterine cavity. In cases presenting such an appearance the cavity is generally enlarged and filled with this fungous deposit. These facts may be ascertained by the use of the probe while the parts are exposed to view.

The microscope will verify and correct our diagnosis. For microscopic examination some substance from the surface of the ulcer or fungoid projection may be collected and submitted for inspection. The appearances are nests or spaces of greater or less size filled with epithelioid cells.

PROGNOSIS.--Without judicious treatment practised at an early period epithelioma may be said to be invariably fatal. There is, however, much promise of great amelioration in this form of disease with the present improved methods of treatment, and in some cases we may succeed in effecting a permanent cure.

TREATMENT.--The general palliative treatment is the same as that described in the other form of cancer, and need not be repeated. While I have failed to see any other than palliative effects result from amputation of the cervix and excavation of the body of the uterus in the first form of cancer described, I have seen cures of epithelioma effected by thorough extirpation of the diseased mass. One of these cures was in a case where the disease was confined to the posterior lip of the cervix; another, where the deposit apparently occupied the whole surface of the mucous membrane of the body and cavity of the cervix. In other cases I am sure the life of the patient was prolonged and her comfort greatly enhanced. I am persuaded, from a good deal of observation, that the younger the patient the more promising the result of operations. The worst and most rapidly fatal cases of epithelioma I have seen have been in patients beyond the menopause. This is contrary to what I have witnessed in the other form of cancer, as in it the younger the patient the more rapid the progress of the disease and the least beneficial the operations were.

After a trial of the several methods pursued in the removal of epithelioma, and the different instruments used for the purpose, I prefer using the scissors, aided by hooks and vulsellum, to cut away as much of the diseased tissue and the sound structure upon which it is implanted as possible, and then burn the surface with the cautery in some of its forms or the strong caustics. When the disease is confined to the cervix, the whole of the intravaginal portion should be cut away and the excising process carried as high up as possible, carefully avoiding the peritoneal cavity on the one hand and the bladder on the other. With the cervix exposed and fixed by a vulsellum, the sharp-pointed curved scissors may be insinuated beneath the external covering, and the tissues removed by pieces until the operation is completed. When the utmost attainable portion is thus removed, I prefer applying to the whole of the cut surface pellets of absorbent cotton thoroughly moistened with the solution of the pernitrate of mercury (the acid nitrate, as it was formally called), and then filling the upper part of the vagina with dry absorbent cotton, {281} tightly packing it so as to absorb any of the free acid. This last is necessary to defend the sound parts from the superfluous cauterization which would otherwise follow. The dressing may be removed in twenty-four hours, and the whole of the surgical cavity as well as vagina washed out with pure warm water twice a day afterward. If the cavity thus formed does not fill up, and the surface assumes a malignant aspect, it should be scraped out with a view to remove its entire surface and treated again with the acid. This last operation may be repeated again and again. It will sometimes be found that the cavity will grow less after each scraping with the sharp curette, and finally fill up.

If the disease is developed in the cavity of the uterus, Simon's sharp curette should be used to scrape out and destroy the whole mucous membrane. When this is done the cavity should be carefully filled with the cotton pellets saturated with pernitrate of mercury, as recommended for the cervical operation. And this operation should be repeated also with the same thoroughness as at first as soon as evidence of a return is manifested. When the scraping and cauterizing have been beneficial the uterine cavity will become smaller, and when the discharges indicate a reproduction of the morbid deposit the surface to be operated upon will be sensibly diminished, until finally it will be apparently almost closed. I say almost, because one of my patients, while she seems to have been cured, still menstruates.

While I do not pretend that many of these cases can be thus cured, I am sure some of them can be. Hence I do not hesitate to recommend an effort to be made in all cases in which the disease has not spread to the adjoining organs or tissues. When a cure is not thus effected, such great amelioration will so often occur as to make an operation justifiable.

The hemorrhages encountered in these operations are generally unimportant, but occasionally so much blood will be lost as to require hæmostatic measures. The practitioner should therefore be supplied with an astringent tampon and use it if necessary.

If an operation for the complete extirpation of the uterus is ever justifiable for malignant disease, I think it is in this form. The operation which I think the simplest and easiest to accomplish is that performed first in this country, so far as I know, by S. C. Lane of the Medical College of the Pacific, and in Germany by Langenbeck.

{282}

DISEASES OF THE OVARIES AND OVIDUCTS.

BY WM. GOODELL, M.D.

The ovaries are two almond-shaped glands attached to either side of the womb by a ligament of contractile tissue called the ovarian ligament, and they are enclosed between the two layers of the peritoneum known as the broad ligament. It has recently been contended that this envelopment in the broad ligament is not a complete one, but that the peritoneum is absent from the posterior surface of the ovary. This has been denied, but even if it be so, the fact does not seem thus far to have any physiological or any pathological bearing.

The ovarian nerves and blood-vessels run between the two layers of the broad ligament, the former coming chiefly from the renal plexuses of the sympathetic, the latter from the spermatic arteries. The ovaries being themselves movable bodies and attached to a movable organ, the exact position of which remains yet a moot question, their own natural situation has not yet been authoritatively determined. His,[1] from an examination of three suicides, holds that the ovary in the adult virgin hangs with its long diameter almost vertical, and with one side against the wall of the pelvis, but below the brim, the free border being behind and the attached end below. Each oviduct is looped over the ovary, rising along the front and falling over behind it. Hence the ovary lies on the fimbriæ which turn back and spread over the summit of the ovary. The ovaries are generally situated on a level with the inlet of the true pelvis, the left one being in front of the rectum, the right one surrounded by a coil of small intestines. When healthy they keep so high up as to be beyond the reach of the examining finger, and consequently they are not impinged upon during coition.

[Footnote 1: _British Medical Journal_, Dec. 10, 1881, from _Archiv f. Anat. u. Entwick._, 1881, Nos. 4 and 5.]

The important and special function of the ovaries--that of secreting and excreting the Graäfian follicles or ovisacs--and their monthly engorgements are the causes of many of the diseases to which they are subject. Hence it is that affections of the ovary, being due most commonly to perverted function, rarely occur before puberty.

Malformations.

Absence of the ovaries is a congenital condition very rarely met with. It is usually associated either with the absence also of the womb or {283} with an imperfect development of the other portions of the sexual apparatus. The breasts will be flat, the vagina generally imperforate, the vulva small, the pubic hair absent, and sexual feeling wanting. Menstruation never takes place. Very commonly the growth of the body is arrested, and the stature is dwarfed to that of a child. Occasionally, however, there is an approach to the masculine type in the size, the figure, the voice, and in the growth of hair on the face and on the body.

An arrested development or a rudimentary condition of the ovaries is a more common malformation than the preceding one. The womb is then infantile in size, and the vulva and vagina are small and the pelvis is narrow. Puberty either fails to take place or it is postponed. When menstruation is present it is scant and appears at long intervals. General development is impaired, and the figure and mental characteristics may be those of advanced childhood. Sexual feeling is either wholly absent or very imperfect.

DIAGNOSIS.--Whenever the ovaries are wanting, their absence cannot be positively made out by a digital examination of the parts, for even fully-formed ovaries often elude the finger. The diagnosis depends mainly on the symptoms previously given. If the ovaries are rudimentary, the finger passed high up the rectum while the woman is anæsthetized will sometimes recognize them. But the diagnosis rests usually on some manifestation of puberty, and the greater these manifestations the greater the curability.

TREATMENT.--For the complete absence of the ovaries all treatment is of course useless. Whenever these organs are in a rudimentary condition more can be done for the woman, but success is by no means assured. Every treatment that tones up the body is of service. The rest-cure, with its accessories of massage, general faradization, and over-feeding, promises much. Electricity has done good when one pole is applied directly over an ovary and the other pole placed either on the sacrum or on the cervix uteri. It is still more efficacious when the reophore in the form of a properly insulated sound is passed into the uterine cavity. Should the interrupted current fail to do good, the galvanic current may cautiously be tried.

From the vascular and nervous kinship between the ovaries and the womb all stimulants to the latter tend to invite blood to the former, and from this flux may come growth. It is therefore good practice to irritate the womb by tents, by applications of iodine and of silver to its cavity, and especially by the use of galvanic stems. The marriage relations sometimes quicken dormant ovaries into life, and development, followed by pregnancy, has been the result. But the remedy is a hazardous one, for if the sexual sense be not awakened, as often it will not, the union leads to much unhappiness.

Inflammation of the Ovary; Ovaritis.

Acute inflammation of the ovary rarely exists per se, but it is by no means an infrequent accompaniment of pelvic peritonitis and pelvic cellulitis, the causes of each being the same. It is then so masked by the {284} greater inflammation that its symptoms are lost in the general ones. Following the same course as that of pelvic inflammations, it begins with fibrinous exudation and ends either in resolution or in suppuration, or in chronic hypertrophy.

The TREATMENT of this inflammation is the same as that of pelvic inflammation--viz. rest, poultices, vaginal injections of hot water, and morphia and quinia in large doses. Sometimes the local abstraction of blood will be useful. Should pus form, it must be evacuated by the aspirator, and preferably per vaginam. After such an inflammation, and especially if caused by gonorrhoea, the ovary usually remains permanently injured, its functions being crippled by fibrous bands, adhesions, hardening of its stroma, and thickening of its investing peritoneum. If both ovaries be thus affected, sterility inevitably ensues.

Chronic Ovaritis.

By chronic ovaritis is meant either persistent congestion of the ovaries, or such tissue-changes in the stroma or in the follicles of the ovary, or in both conjointly, as are brought about from a previous attack of acute inflammation or from persistent hyperæmia. In its early stages it appears to be characterized by passive congestion, followed by infiltration of sero-sanguinolent fluid and by increase in bulk. Later on, if the congestion be not dispersed or it passes the health-limit, it becomes formative, or nutritive; the capsule thickens, the follicles enlarge, and a general hypertrophy takes place. According as the brunt of these changes falls on the stroma or on the follicles, the degeneration is termed either interstitial or follicular. When the stroma is chiefly attacked, the ovary becomes hard and rugous; when the follicles are diseased, they increase in size, and one or two of them are usually found to be distended into miniature cysts. There are indeed good reasons for the opinion that an ovarian cyst is a dropsy of many ovisacs, and is caused by ovaritis. The left ovary is the one more commonly affected--a fact accounted for by the pressure of the distended rectum and by the emptying of the left ovarian vein into the renal vein instead of into the vena cava, which is the course of the ovarian vein on the right side. It is a very common form of disease, very rarely coming from an acute attack, but starting subacutely with all the symptoms of chronicity.

CAUSATION.--Whatever induces a lasting congestion of the reproductive apparatus tends to create ovaritis--a torn cervix, a lacerated perineum, an arrest of involution after labor, dysmenorrhoea, and uterine tumors, flexions, and displacements. Barren women are very liable to this disease, and so especially are women who shirk maternity by preventive methods; for in both the menstrual congestions continue without that much-needed break which gestation and lactation bring, and in the latter the sexual congestions arising from incomplete intercourse are not relieved. So repeated erectility from self-abuse, by ending in a passive congestion of the womb and of the ovaries, will tend to produce this lesion. The prevalence of this habit in unmarried women is, I think, very much overrated, and yet I have seen from this cause several cases of ovaritis accompanied with prolapse of the ovaries. In one the ectropion {285} of the cervical mucosa was so marked that it leads me to think that this is the cause of the occasional inversion of the womb in virgins. My notebook shows also cases of ovaritis from such imperfect sexual relations as come from the ill-health or the advanced age of the husband, and not a few from immoderate sexual intercourse. Some of the most common causes of chronic ovaritis are emotional in character, such as long engagements, disappointments in love, single life, the reading of corrupt literature, unhappy marriages, nerve-exhaustion, and hysteria. These causes operate by producing circulatory disturbances which keep up a constant congestion of such exacting organs as the ovaries.

SYMPTOMS.--Pain in one or in both ovarian regions, especially in the left one, is a prominent symptom. It is increased by walking or by standing, and is lessened by the recumbent posture. Starting usually from the ovary, it radiates to the small of the back or down the inner side of the thigh. It often begins from a week to ten days before the monthly period, and goes on increasing until the flow appears, when it commonly abates. Menorrhagia may usher in the disease, and may continue during the remainder of menstrual life, which then is usually prolonged. Ordinarily, however, menstruation becomes scant and irregular, postponing rather than anticipating. Sometimes amenorrhoea takes place. Sterility is usually present, and so almost always is nerve-exhaustion with all its emotional manifestations. Pressure over each ovarian region elicits pain and causes a contraction of the rectus muscle on the affected side. The finger per vaginam or per rectum will often discover behind the cervix uteri or to one side of it the very tender ovary, of the form and size of an almond. Pressure on it gives a sickening pain, very unnerving in its character. Reflex nervous symptoms are very common, especially those of hysteria. In the form of pain they show themselves in backache, spine-ache, nape-ache, and headache; in pain under the left breast, in the scalp on the top of the head, and in the stomach, bowels, womb, and coccyx. Nervous dyspepsia is common, accompanied by costiveness, nausea, vomiting, flatulent distension, and noisy eructation. Wakefulness and bad dreams are not infrequent. Other reflex neuroses may appear, such as paralysis or spasm of the sphincter muscles, the latter producing asthma, dysmenorrhoea, irritable bladder, and painful defecation. Then, again, there may be nervous disturbances, taking the form of low spirits, violent hysterical attacks, epilepsy, hystero-epilepsy, and of positive mental aberration.

PROGNOSIS.--This disease is rarely fatal, but it is always very stubborn, and often incurable. The patient grows anæmic and she tires on the slightest exertion. Very soon nerve-exhaustion with its protean symptoms sets in. She takes to her back and becomes a sofa-ridden invalid. If the patient has contracted the habit of taking stimulants or anodynes, her chances for recovery will be greatly lessened.

TREATMENT.--The pelvic organs should be carefully examined, and any discoverable lesion of the womb and of its annexes be remedied. Pelvic engorgement must be met by keeping the bowels soluble, by scarification of the cervix, by large vaginal injections of water as hot as can be borne, and by vaginal suppositories of belladonna and by rectal ones of iodoform. Tenderness and hardness in either broad ligament is first treated by applications of a strong tincture of iodine both to the roof of {286} the vagina and to the skin overlying the ovarian regions. Flying blisters may also be placed there with benefit. Sexual intercourse should not be indulged in unless the desire for it be strong or there is a possibility of conception, for, by the prolonged rest which it gives to the ovaries, pregnancy usually brings about a cure. The patient should keep on her back during her menstrual period; but, while rest in the recumbent posture should be taken morning and afternoon, she should be encouraged to move about and exert herself in some light household work, yet not to over-fatigue herself.

As far as medicines are concerned, those should be chosen which lessen the engorgement of the reproductive organs. Thirty grains of potassium bromide and ten drops of tincture of digitalis, given in compound infusion of gentian before each meal, will tend to quench all erectility of these organs. After the patient has been kept for some time on these anaphrodisiacs, alteratives will come into play: very good ones are ammonium chloride and mercuric bichloride, which can be advantageously administered after the following formula:

Rx. Hydrargyri chloridi corrosivi, gr. j-ij;
Ammonii chloridi, drachm ij-iv;
Misturæ glycyrrhizæ comp. fluidounce vj. M.

S. One dessertspoonful in a wine-glassful of water after each meal.

The paregoric in this mixture helps to control the aches; the antimony adds its quota to the needed alterative action; and the licorice disguises the harsh taste of the ammonium chloride.

Another very excellent alterative and nervine is the chloride of gold and of sodium. It is best given in pill and after each meal in doses of from one-eighth to one-quarter of a grain.

As there is in this disease a craving after stimulants and anodynes, which often degenerates into intemperance and into the opium-habit, the physician should be very careful how he prescribes such remedies, reserving their use wholly for emergencies.

In plethoric cases marked with menorrhagia iron is hurtful, but in anæmic cases with scant menstruation it rarely fails to do good, especially when given conjointly with arsenic. An excellent combination is one part of Fowler's solution of arsenic to nine of the syrup of the ferrous iodide. Beginning with ten drops after each meal, the patient increases the dose daily by one drop until thirty drops are reached. She then continues this last dose as long as it does good or it can be borne. In stubborn cases a sea-voyage may prove of lasting benefit.

The best of all treatments, however, and by far the best, is that devised for nerve-exhaustion by S. Weir Mitchell, which goes by the name of the rest-cure. It consists of prolonged rest in bed, seclusion from friends, massage, electricity, muscular movements, and a diet consisting largely of milk. By this treatment the circulation of the blood is made equable and the ovaries and other pelvic organs are thus relieved of their turgescence. I have had wonderful cures from this treatment, and can recommend it with the utmost confidence. Bed-ridden patients have been restored to health and chronic invalids returned to society.

Once in a while, lasting tissue-changes take place in the ovaries which medication cannot reach. The question then comes up, whether the woman shall be doomed to drag out the rest of her menstrual life {287} burdened with distressing ovaralgia, with crippled locomotion, and with pelvic aches and pains and throbs, or whether the source of all these mischiefs, the ovaries themselves, shall be extirpated. This is a very important question, and the removal of these organs should not be decided upon without careful deliberation and without the conviction that the disease is otherwise incurable.

Prolapse of the Ovary.

This displacement of the ovary is almost always one of the lesions of chronic ovaritis, and as such might have been discussed under that general heading. But as it displays certain symptoms peculiar to itself, and needs a special treatment aside from the general one, it seems to me best to describe it by itself.

At every monthly period the ovaries become turgid with blood, and from their weight sink low down. They can then be often felt, and even outlined, in Douglas's pouch. When this congestive period is over they discharge their over-freight of blood and again float up out of reach. Unfortunately, however, they sometimes keep turgid--blood-logged, so to speak--and consequently become permanently displaced. Accompanying this dislocation there will generally be some uterine lesion which will stand in the relation either of cause or of effect.

Nor could it very well be otherwise, for very close is the vascular and nervous kinship between the two--so close, indeed, that turgidity in the one means erectility in the other. Hence it is not always easy to decide which lesion was primary and which is secondary. When one ovary is displaced, it is usually the left one, because the left ovary, as explained under the heading of Ovaritis, is the one more liable to disease. When both ovaries are displaced, the left one will be the lower and the more easily reached, because the left round ligament is the longer and the left side of Douglas's pouch the deeper.

CAUSATION.--Any condition tending to a lasting congestion of the reproductive apparatus is very likely to lead to a descent of the ovaries. The causes, therefore, are the same as those of chronic ovaritis, to which subject the reader is referred.

SYMPTOMS.--First and foremost is pain in locomotion. Since the ovary now lies between the womb and the sacrum, it is liable at every step to be pinched between them. This pain is referred to the inguinal and sacral regions, and is of a sickening and an unnerving character. It often occurs suddenly, and then runs down the corresponding thigh along the track of the genito-crural nerve. One of my patients would, while walking, be unexpectedly seized with such a pain, which would either momentarily cripple her or else last so long as to compel her to call a carriage. Her left ovary, until cured by treatment, behaved like a loose cartilage in the knee-joint, and slipped down so low as to get pinched.

A second symptom is a throbbing pain while the rectum is loaded, and an agonizing pain during defecation. This arises from the grating of the hardened feces over these tender glands. In one of my cases[2] rectal enemata or the presence of hardened feces kindled up sexual throbs of the {288} most painful and exhausting character, which thrilled through the whole body for hours at a time.

[Footnote 2: _Lessons in Gynæcology_, by W. Goodell, M.D., ed. 1880, p. 332.]

A third symptom is painful coition, for the ovaries are now so low down as to be bruised by the male organ. A fourth is gusts of pain radiating from either groin. Lastly, there is usually present a morbid state of the mind, accompanied by low spirits. I have seen suicidal tendencies evoked by dislocation of the ovaries and relieved by their replacement.

DIAGNOSIS.--A digital examination will discover in Douglas's pouch a very tender almond-shaped body on one side of the womb. If both ovaries are dislocated, two such bodies will be found; but the left one, for reasons previously given, will be lower down and more easily defined. Pressure upon one of them produces a sickening pain, like that when the testicle is squeezed. If the pressure be increased, and be so made that one of these bodies slips abruptly away from under the finger, such a thrill of indescribable pain darts through the groin and down the side of the corresponding thigh that the woman screams out and grows pale or becomes nauseated.

A dislocated ovary is sometimes mistaken for a pedunculated fibroid tumor of the womb or for the fundus of a retroflexed womb. But the uterine growth is not sensitive to the touch, and the flexion of the womb can always be told by the sound.